Extended endoscopic endonasal resection of craniopharyngioma using intraoperative visual evoked potential monitoring: technical note.

BACKGROUND: To avoid deterioration of visual function, extended endoscopic endonasal transsphenoidal surgery (TSS) for craniopharyngioma was performed with visual evoked potential (VEP) monitoring using light-emitting diodes (LEDs). METHODS: The position of the optic chiasm was carefully evaluated on the preoperative midsagittal magnetic resonance (MR) images. Intraoperatively, direct and sharp dissection of the tumor from the optic chiasm was performed under VEP monitoring with LEDs through extended endoscopic endonasal TSS. If the VEP finding changed and became unstable, the operator were informed and stopped the surgical manipulation for the optic chiasm to recover. After 5-10 min, recovery of VEP findings was checked and the procedure resumed. RESULTS: Extended endoscopic endonasal TSS with VEP monitoring was performed in consecutive 7 adult patients with newly diagnosed suprasellar craniopharyngiomas with maximum diameters of 25-41 mm (mean 33.7 mm). VEPs were stable throughout the surgery in 5 cases, but showed temporary instability and amplitude decrease in 2 cases, although the VEPs had recovered at the end of the surgery. Visual function, evaluated using visual impairment score, was improved after surgery in all patients. Gross total removal was achieved in 5 cases, and subtotal removal (90%) in 2 cases. CONCLUSIONS: Intraoperative VEP monitoring is the only way to test visual function during surgery, and may be important and helpful in extended endoscopic endonasal TSS, which requires direct dissection between the optic nerve and craniopharyngioma under the endoscope.

Neurolymphomatosis secondary to primary central nervous system lymphoma: illustrative case.

BACKGROUND: Neurolymphomatosis (NL) is a rare disease defined as an invasion of lymphoma into peripheral nerves, nerve roots, or nerve plexuses, including the cranial nerves. No clear treatment protocols have yet been defined for this pathology. OBSERVATIONS: A woman in her 40s had a primary central nervous system lymphoma diagnosed from an intracranial tumor biopsy and underwent chemotherapy and radiation therapy. After she complained of pain in the trunk and extremities, magnetic resonance imaging and [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) performed 25 months after initial diagnosis revealed multiple lesions in the nerve ganglia, plexuses, and peripheral nerves from the cervical to the sacral spinal cord. Cerebrospinal fluid cytology revealed atypical lymphocytes and lymphoma dissemination in the spinal cavity. Based on these findings, NL was diagnosed. An intrathecal antineoplastic regimen temporarily reduced abnormal uptake of FDG, but the lesion recurred. After additional high-dose methotrexate therapy, FDG accumulation in the previously identified lesions disappeared. However, peripheral neuropathic pain and paraplegia remained. The patient died 9 months after the initial diagnosis of NL. LESSONS: The authors reported a case of NL following primary central nervous system lymphoma. In this case, FDG-PET proved useful for diagnosis, and high-dose methotrexate therapy was temporarily effective. https://thejns.org/doi/suppl/10.3171/CASE24107.

[Intra-tumoral hemorrhage caused by foramen magnum meningioma: a case report].

Intratumoral bleeding from a meningioma is very rare. We herein report a case of a foramen magnum meningioma which presented in association with intratumoral bleeding. A 49-year-old female who had been suffering from occipital headache and shoulder pain on neck motion was referred to our hospital to undergo treatment for a tumor located in the posterior fossa. Magnetic resonance imaging (MRI) demonstrated a foramen magnum meningioma which originated at the lower clivus and extended to the C2 level of the vertebral column. Marked compression and distortion of the medulla oblongata and spinal cord was also noted. Surgery was therefore planned. The patient thereafter suffered from a sudden onset of headache, vomiting and hoarseness, and was transferred to our hospital. A computed tomography (CT) showed intratumoral bleeding, which extended to the subarachnoid space and the fourth ventricle. The tumor, as well as the massive hematoma, were both immediately removed. The histological diagnosis was meningothelial meningioma. We also reviewed the pertinent literature and propose the possible mechanism for such tumor bleeding in this particular location in which the blockage of the cerebrospinal fluid caused a craniovertebral pressure gradient, which thus resulted in intratumoral bleeding.

Multi-slice computed tomography-assisted endoscopic transsphenoidal surgery for pituitary macroadenoma: a comparison with conventional microscopic transsphenoidal surgery.

OBJECTIVES: Intraoperative computed tomography (iCT) is a reliable method for the detection of residual tumour, but previous single-slice low-resolution computed tomography (CT) without coronal or sagittal reconstructions was not of adequate quality for clinical use. The present study evaluated the results of multi-slice iCT-assisted endoscopic transsphenoidal surgery for pituitary macroadenoma. METHODS: This retrospective study included 30 consecutive patients with newly diagnosed or recurrent pituitary macroadenoma with supradiaphragmatic extension who underwent endoscopic transsphenoidal surgery using iCT (eTSS+iCT group), and control 30 consecutive patients who underwent conventional endoscope-assisted transsphenoidal surgery (cTSS group). The tumour volume was calculated by multiplying the tumour area by the slice thickness. Visual acuity and visual field were estimated by the visual impairment score (VIS). RESULTS: The resection extent, (preoperative tumour volume - postoperative residual tumour volume)/preoperative tumour volume, was 98.9% (median) in the eTSS+iCT group and 91.7% in the cTSS group, and had significant difference between the groups (P = 0.04). Greater than 95 and >90% removal rates were significantly higher in the eTSS+iCT group than in the cTSS group (P = 0.02 and P = 0.001, respectively). However, improvement in VIS showed no significant difference between the groups. The rate of complications also showed no significant difference. DISCUSSION: Multi-slice iCT-assisted endoscopic transsphenoidal surgery may improve the resection extent of pituitary macroadenoma. Multi-slice iCT may have advantages over intraoperative magnetic resonance imaging in less expensive, short acquisition time, and that special protection against magnetic fields is not needed.

Discrepancy in EBV-DNA load between peripheral blood and cerebrospinal fluid in a patient with isolated CNS post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disorder (PTLD) is a fatal complication of allogeneic hematopoietic stem cell transplantation (HSCT) that is caused by reactivation of Epstein-Barr virus (EBV). A successful approach, monitoring EBV-DNA load in peripheral blood (PB) accompanied by preemptive rituximab therapy, has recently been reported. Here, we describe a 29-year-old woman who developed isolated central nervous system (CNS) PTLD. She received HSCT against acute myelogenous leukemia from a related human leukocyte antigen-haploidentical donor, following a conditioning regimen that included antithymocyte globulin. Tacrolimus and methylprednisolone were given as prophylaxis for graft-versus-host disease. On day +172, the patient's consciousness deteriorated. Magnetic resonance imaging showed six ring-enhanced lesions in the cerebral hemispheres. These tumors were diagnosed, via a craniotomy and tumorectomy, as PTLD. EBV-DNA load was elevated in the cerebrospinal fluid (CSF) but not detected in PB. She was treated with whole-brain irradiation and rituximab, and achieved partial remission of the tumors. This case serves as a reminder that vigilance is required regarding the development of isolated CNS PTLD; it is worth examining EBV-DNA replication in CSF for diagnosis even when the EBV-DNA load is negative in PB.

Benefit of carotid endarterectomy for symptomatic and asymptomatic severe carotid artery stenosis: a Markov model based on data from randomized controlled trials. Clinical article.

OBJECT: Several major randomized controlled trials of carotid endarterectomy (CEA) in patients with both symptomatic and asymptomatic carotid artery stenosis have addressed the net effects of CEA on the risk of stroke. However, because the risk of stroke among patients with asymptomatic carotid stenosis is relatively low, whether to treat their stenosis with CEA remains an important public health issue. METHODS: The authors constructed a Markov model to evaluate the effectiveness of CEA. In modeling 4 health states, the probability of transition to another state was estimated using data from major randomized controlled trials. Adopting 3 comorbidity index values for baseline analyses, the authors expressed outcomes in terms of the expected number of quality-adjusted life years (QALYs) for a hypothetical cohort undergoing CEA and another without treatment. RESULTS: In the authors' baseline analysis, CEA for asymptomatic stenosis yielded a very small benefit (0.07 QALY) for 70-year-old, normal-risk CEA candidates. Benefits decreased further, often becoming negative, as patient age, surgical risk, or comorbidity index increased. In patients with symptomatic stenosis, CEA was always more effective than conservative management, even considering variables such as comorbidities limiting life expectancy, advanced age, and increased perioperative risk. CONCLUSIONS: Carotid endarterectomy for severe carotid stenosis consistently and significantly benefits patients with recent symptoms. However, surgery for asymptomatic stenosis appears justified only in carefully selected conditions: low treatment risks in relatively young individuals without any comorbidities.